ACL Research Paper

Caitlyn Hodgkinson, Nora Dewart & Vanessa Costa

The University of Guelph-Humber

March 24th, 2017

Introduction

The Anterior Cruciate Ligament (ACL) is one of the key ligaments attaching the femur to

the tibia. The ACL prevents anterior translation of the tibia with respect to the femur and

provides rotational stability. Over 50% of injuries to the ACL occur simultaneously with other

ligament or meniscal tears. The unhappy triad is a term that describes the most common tissues

that are often injured alongside the ACL, and include; the medial meniscus and MCL. Over 2/3

of ACL tears occur due to non-contact movements, such as: pivoting, jumping, side stepping,

cutting. The remaining ACL incidents occur from acute, direct physical contact.

Female athletes are at increased risk for ACL injuries, which can be attributed to a

number of mechanisms. The primary reason is due to the anatomy of womens pelvis, which

tend to be wider; thereby creating a greater Q angle. A q-angle is an angular representation

from ASIS to the patella of the force produced by the quadriceps muscle group. Having a

greater Q angle puts more pressure on the medial portion of the knee, causing a greater valgus

force during landing and movements that involve sudden changes in direction. Another reason

why women are at higher risk of ACL injury is due to increased laxity of their ligaments

compared to those in men. This increased joint movement can lead to potential overstretching

and thus tearing in said ligament. The last main reason that prevalence is higher in women, can

be attributed to the size of the ACL itself, in women the ACL is smaller and therefore more

susceptible to tear than a bigger counterpart.

Differential Diagnoses

For ACL diagnoses, usually imaging tests such as MRI are first used to screen for any

injury, although some doctors might also request an X-ray to confirm if there is any bone

fracture associated to a soft tissue injury. After the results of the tests are known, the surgeon

might want to confirm the diagnosis with further physical examination of the knee (Lachman,

pivot shift, ADTIR). The reason for the physical diagnoses to be performed after the imaging

tests is to allow proper rest and decrease the swelling and pain during the first two weeks

post-injury, before performing a painful physical examination on the injured structures.

About 50% of ACL injuries occur with damage to other surrounding knee structures such

as meniscus, articular cartilage or other ligaments.

ACL injury severity is graded the same way as all other ligaments, having 3 classification

categories: Grade 1, the ligament has some damaged and was slightly stretched but still has the

ability to keep knee stability. Grade 2, the ligament is stretched to the point where it becomes

loose, representing a partial tear of the ligament. Grade 3, represents a complete tear of the

ligament, there is instability of the tibial movement and no pain associated as the ligament is

split into two pieces.

Treatment Options

Treatment approach for ACL will depend upon individuals needs including; activity level,

time to full recovery and lifestyle. The younger, active individual will need a surgical treatment

approach in order to guarantee full safe return to sports with sudden changes in direction, agility

and unpredictability. A torn ACL ligament does not heal and regrow without surgery, although,

non-surgical treatment can be a viable option for elderly or non-active population. If all the other

structures of the knee are intact, bracing and physical therapy might be a viable option for

specific population groups.

ACL reconstruction surgery is the recommended option for athletes as it ensures knee

stabilization and thus return to play can ensue despite the injury. Over 80% of individuals who

opt out of ACL reconstruction will develop a meniscal tear within the next 10 years (Luks, 2014).

The prevalence of people receiving ACL reconstruction surgery is just over 50% of incidences

each year (Misyanka, Daniel & Stone, 1991). It is important to understand the post-operative

protocol of what happens with an individual who undergoes surgery to repair their ACL and/or

meniscus in order to return-to-play.

The ACL reconstruction consists of a full reconstruction of the ligament, where the torn

ligament is replaced with a tissue graft. This graft acts as a scaffolding for the new ligament to

grow. There are different graft sources: Autograft and Allograft. Autograft is usually the preferred

choice of most surgeons as it has a reduced recovery time and less probability of rejection and

future infections. These type of graft consists of a part of a muscle from the individual that is

operated (usually patellar tendon, hamstring tendon, and quadriceps tendon), being used as a
graft for the new tendon. Regarding allografts, they consist of an ACL tendon usually obtained

from a motor vehicle accident donor.

Both options can be beneficial and have a high rate of client satisfaction, although, there

are differences in stability, strength, function, time of recovery and cost. Regarding stability,

there is a very identical level of stability between both options. Regarding strength, there is a

noticeable decrease between autograft hamstring tendon use compared to quadriceps tendon

use. Three out of seven studies showed a significant deficit in Hamstring strength. Regarding

knee function, there were no statistically significant differences in studies comparing allograft

and autograft. Regarding risk of infection, it was shown that allograft imposes a higher risk in

disease infections such as HIV or hepatitis. Also, regarding risk of rupture, some studies have

shown that using allograft in younger aged active individuals can impose a higher risk of

rupture. Cost Wise, the autograft represents a significant decrease since the average cost of an

allograft is around one-thousand dollars (Macauly, 2012).

Post-Operative Rehabilitation

3-Days

Following surgery, it is common to have swelling and feel discomfort, ensure to ice the knee 3 to

4 times per day for 20 minutes at a time. Tylenol is the preferred medication for pain relief

because it is not shown to slow the healing process with any anti-inflammatory mechanisms.

The primary focus during this stage post-surgery is to increase passive range of motion.

Passive range of motion involves muscles and joints that are passively involved without the

strain of active motion. Passive range of motion exercises can be performed at home with the
assistance of a family member, towel, resistance band, wall or in the clinic. Progression of

passive range of motion exercises towards 60 degrees of flexion is ideal for 3 days post

surgery, but can be modified to what is tolerated by the individual patient and their specific

progressions. It is common to have blood pooling in the calf region of the lower leg post surgery

so performing pedal foot dorsiflexion exercises repeatedly helps pump the blood back to the

heart to prevent blood clots. Crutches are used to assist in gait using the Three Musketeers

method which refers to when walking plant both crutches at the same time, then follow with

non-surgical leg. When performing stairs, the step up involves: plant crutches and non-surgical

leg on step and then follow with surgical leg. When stepping down: the surgical leg and crutches

should touch ground at same time while non-surgical leg is still on the step in a bent/lunge

position.

1 Week

Patients are encouraged to progress to full weight bearing as tolerated with knee straight, and

brace locked at -10 degrees extension until cleared by physcian. Manual therapy can

commence to reduce swelling by using the milking technique to dissipate fluid accumulation in

different regions surrounding the knee. Increasing passive range of motion (PROM) as well as

introducing neuromuscular quadriceps activation (single leg raises) are the primary focus at this

point in rehabilitation. PROM can be increased to 90 degrees of knee flexion and 0 degrees

extension.

2 Weeks

Quadriceps strengthening exercises can be introduced into the patients rehabilitation

protocol. The strengthening exercises are essentially the activation exercises that were
performed in the earlier stages but with added load from an ankle weight. To increase blood

flow and ROM, passive stationary biking can be incorporated to the patient's rehabilitation.

Starting with seat height higher and then progressively bringing the seat lower as ROM

increases in the surgical leg. Passive cycling involves the non-surgical leg doing the active

pedalling; while the surgical leg is passively pulled through the motion. Ensure the patient is not

looking down while pedaling but looking straight forward to reduce the quadriceps activation

while pedalling. PROM exercises are still performed during this stage of training working

towards 90 degrees flexion, which are mentioned above to help increase ROM. If the patient is

experiencing any knee pain, clicking or clunking with passive flexion, they could benefit from the

use of k-tape. K-tape would help by pushing the patella medially to assist with proper tracking of

the patella caused by atrophy of the quadriceps. When performing biking or other exercises,

ensure that there is no hamstring stretching until 4 weeks, in order to prevent stretching of the

graft with autograft repair.

3 Weeks

Full ROM should be reached with ACL reconstruction, but restrict to 90 degrees flexion if

meniscal repair was performed. Crutches can be discontinued if gait is normalized, knee is pain

free, has good quadriceps tone, no extensor lag and no dynamic valgus. Continue with passive

cycling on stationary bike, progressively lowering the seat as ROM increases. Along with

exercises working on quadriceps strengthening in the week 2, the patient can start to add in

gluteus medius focused exercises which can include: clam shells and side leg raises. Also calf

raises and side planks can be added into the rehabilitation protocol. Continue icing to help with

swelling and pain management. Continue using k-tape for proper positioning of the patella if

needed.
4 Weeks

By four weeks post surgery, full weight bearing should be incorporated with leg straight in brace

locked at -10degrees. If patient has full extension, no extension lag, no pain and good

quadriceps contraction they can gradually wean off brace as tolerated. Full ROM is the main

priority for ACL repair patients. Hamstring stretching can begin as tolerated, but ensure that

hamstring contraction is not occurring with patients who received autograft. Progress to

isometric exercises (60 deg wall sit) only if no meniscal repair was done and hip/core

strengthening exercises (abdominals, gluteus maximus/medius). Patella mobilization can also

be added to help alleviate stiffness in the patella. Continue with ice and k-tape for patella

tracking as needed.

5 Weeks

Full ROM should now be achieved with meniscal repair, and as listed in 4 weeks post surgical

ACL repair, full ROM should be achieved and as previously stated is the main priority. If this is

not reached, discontinue with the use of the brace as an attempt to help with increasing ROM. It

is important to show patients how to walk safely with stiff leg without the brace, as this

movement is not familiar to them. Strengthening exercises are the same as introduced in week

4 above. Continue with patella mobilization, ice and k-tape for patellar tracking as needed.

6 Weeks-4 Months
At this stage hamstring strengthening can begin it is suggested that patient begins with single

leg biking (surgical leg) with increasing resistance. Continuing with mini-squats (<60 degrees),

step-on/off raised platform,double leg bridge, leg curls. Also added in balance/proprioception

exercises (star exercise, bosu ball, trampoline), core/back strengthening while progressing to

closed chain exercises (wall sits with ball, shallow lunges). Begin single leg strengthening at 3

months with single leg bridges, single leg wall sit, and stationary reverse lunge. Ensure that

exercises are started off statically and once good form has been achieved progress to dynamic

movements. K-tape can be used for patellar positioning for proper tracking if needed.

4-6 Months

By this point in the rehabilitation protocol, the focus should be around sport specific exercises.

Begin staging exercise progressions for return to sport/physical activities (see below for staging

progression). By 4 months, (5 months if meniscal repair) running on a treadmill can be added if

the patient is able to perform 10 single leg squats with no dynamic valgus. By 5 months, lateral

stepping exercises can be introduced and by 6 months cutting, pivoting and deep knee bend

activities can be incorporated if cleared by physician. Closed chain exercises can continue to

be implemented, making them more sport specific if patient is pain free. Closed chain

exercises are used because they produce less shear forces to the knee joint.

6-9 Months

The primary issue seen in this phase of rehabilitation is poor knee tracking attributed to lack of

neuromuscular ability and balance. By this point, quadriceps and hamstring strength are at a

sufficient level so the musculature is not what is limiting. To strengthen the neuromuscular
connection and balance, specific staging progressions are incorporated which involve single leg

hops in a linear and diagonal direction.

Staging

All of the stagings are performed on the surgical leg with the hands on the stomach to observe

for any rotation of the pelvis. The first stage is a single leg stance, it is important to achieve a

stable knee without valgus or varus movements with no weight shift in the hips. Once the single

leg stance has been achieved, the patient can progress into a dynamic single leg squat. There

should be a fist width between the two legs, with the non-surgical leg flexed at 90 degrees. At

this stage, it is important to keep observing for knee valgus or varus movements and overall

proper knee tracking. Starting the single leg squat stage at 20 degree flexion of the surgical leg,

working towards 40 degree knee flexion and graduating to the next stage once 60 degrees of

knee flexion with proper form is achieved. The next stage involves performing a single leg squat

while looking left and right. The added difficulty in this stage is through manipulating

proprioception. Ensuring proper knee tracking that was observed in the earlier stages is

important to see at this stage as well. The patient can progress to the next stage once 10

repetitions of single leg squats while looking left and right are achieved. The next progressions

of the stages involve the same movements as the previous stages, but on a different surface.

These stages involve performing a single leg stance, a single leg squat and a single leg squat

while looking left and right performed on a trampoline. The trampoline mimics the uneven

surface of most sporting turf and is thus optimal for a return-to-play rehabilitation program. The
final progression of this phase of staging is single leg squat on trampoline with perturbation.

Perturbation imitates what it will be like in a game setting to have defensive players of the other

team come in contact with you. During this stage perturbation is done at the hip, the knee and

then the shirt pull. It is important to develop the appropriate balance and compensatory

movements to perturbation during a rehabilitation protocol in order to decrease the likelihood of

re-injury when patient is re-introduced into the game setting.

The neuromuscular progressions are performed following the perturbation staging. The

neuromuscular staging stress the importance of muscle activation, balance and overall control.

The first neuromuscular stage involves single leg hopping in a straight line. At this stage, it is

important to maintain proper knee tracking and hip alignment. After the linear single leg hops,

single leg cross hops can be performed. The last stage before completion of the rehabilitation

protocol involves the successful execution of a single leg hop onto a trampoline.

Conclusion

The goal of the protocol was to slowly progress from a passive ROM reestablishment, decrease

inflammation and preserve repair phase to the strengthening of the structures around the joint

while allowing meniscal repair. The very last phases must be more stabilization, proprioception

and performance specific especially if we are talking about athlete rehabilitation.

Phase 7 reinforces and simulates action during a soccer game such as landing during a header,

or changing direction or even a side tackle at the knee where it is fundamental to keep proper

patellar traction and alignment. A study as showed that the progression of a rehab protocol

should start by an increase in the duration of the session and further increase in intensity, with

ultimate integration of sport specific drills and functional proprioception training (Mangine, 2008).
In the initial phase, no squatting or knee flexion would pass 60 degrees to maintain full integrity

of the medial meniscus. (Pabjan, 2008).

I chose to delay the hamstring strengthening to allow a increasing in extension ROM in the first

phases, which were the main priority, decreasing antagonistic contraction. Also as the patient

had an autograph, it could be to soon to conduct any hamstring related strengthening exercise.

Also I chose to have one full strengthening phase focused on single leg exercises, studies have

shown that the high levels of quadriceps activation sustained during exercises such as single

leg squat and step-ups are very effective for muscle rehabilitation and re-education (Beutler,

2002).

The decision to have a lower-body strengthening approach with only closed chain exercises is

due to the belief in the rehabilitation world that closed chain exercises represent a greater

benefit stability-wise and is safer, reducing torque and compressive force at the joint. A study

showed that closed chain exercises were more effective mobilizing the joint then open chain

exercises, and also provided a quicker recovery and return to sports and physical activity (Uar,

2014).
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